Abstract
Background
Postpartum hemorrhage is one of the leading causes of maternal morbidity and mortality worldwide and the second most frequent cause of pregnancy related death in the United States. There are discernible differences among healthcare providers in identifying risk factors and managing obstetric hemorrhage. Furthermore, there is limited data on patient’s awareness and attitudes toward hemorrhage risk factors and preventive measures, as well as their involvement in clinical decisions. This project aimed to identify educational gaps for providers and patients in preventing and managing postpartum hemorrhage to optimally reduce maternal morbidity and mortality.
Methods
Cross-sectional anonymous surveys were distributed among obstetric patients and providers at a single maternity healthcare center from November 2022 to June 2023.
Results
The study cohort included 629 patients and 22 providers. Most of participants, 84% (n = 526), lack knowledge or are uncertain about the risk factors associated with postpartum hemorrhage. When participants were asked how likely they would be willing to accept a preventative medication to reduce the risk of postpartum hemorrhage, 55% (n = 344) responded “very likely” followed by 28% (n = 176) as “somewhat likely”. Patients are likely to accept preventative medications to reduce the risk of postpartum hemorrhage. The majority of providers, 73% (n = 16), express confidence in using tranexamic acid for postpartum hemorrhage treatment.
Conclusion
There is lack of knowledge among pregnant patients about the risk factors for hemorrhage and the standard medications to prevent it. Despite this, most participants are willing to receive preventive medication. Practice patterns regarding the prevention and management of hemorrhage should be part of a shared decision making between patients and providers.
Keywords
Introduction
Obstetric hemorrhage is one of the leading causes of maternal morbidity and mortality worldwide and is a significant threat to maternal well-being and survival. 1 Over the last 20 years, trends in postpartum hemorrhage (PPH) in the United States have increased from 2.7% to 4.3%. 1 Recent data from Centers for Disease Control and Prevention 2017–2019 Maternal Mortality Review Committees reports hemorrhage as the second most frequent cause of pregnancy-related death in the United States and 80% of all pregnancy-related deaths were determined to be preventable. 2
Several factors contribute to the increasing rates of PPH. Changes in maternal demographics, such as advanced maternal age and increased prevalence of obesity, have been associated with higher PPH risk. Additionally, the rise in cesarean delivery rates, prolonged inductions, and higher incidence of conditions like placenta previa and accreta have been linked to the trend.1,3,4
Current management guidelines for PPH vary across countries, reflecting differences in healthcare systems, resource availability, and clinical practices. In the United States, the American College of Obstetricians and Gynecologists (ACOG) recommends active management of the third stage of labor, including the use of uterotonic agents such as oxytocin, early cord clamping, and controlled cord traction. In contrast, the United Kingdom’s National Institute for Health and Care Excellence (NICE) guidelines also advocate for active management but differ in their recommendations on the timing of uterotonic administration and cord clamping. Similarly, guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC) emphasize the use of oxytocin and consider additional measures like uterine massage and the use of tranexamic acid in specific situations. Australia and New Zealand follow the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) guidelines, which include recommendations for active management and tailored interventions based on risk assessment. These variations highlight the need for a standardized approach to PPH management to ensure consistent and effective care across different settings.
There is considerable variation in PPH management guidelines across major national Obstetrics and Gynecology organizations in the United States, Canada, England, Australia and New Zealand.3,5 None of these organizations report specific recommendations regarding prevention strategies, specifically before the onset of third stage of labor. 3 Furthermore, inconsistency among PPH definitions and lack of consensus surrounding management and treatment of obstetric hemorrhage underlines the need for universal approach to education and management of hemorrhage to improve outcomes.3,4,6–8
Establishing preventive measures even before conception, taking into account risk factors for further stratification and patient reported outcomes may result promising. 5 Little is known from the patient’s perspectives and there is a lack of evidence gathered from the patient’s experiences and attitudes towards prevention and management of PPH.4,9–15 In one of the largest questionnaire studies assessing the patient’s experiences and outcomes during and after PPH, areas improvement in clinical care were identified such as the way professionals counsel and educate patients and their partners before, during and after PPH. Among other findings, the insufficiency in communicating information about hemorrhage such as risk factors, causes, and treatment possibilities as well as the lack of including patients’ opinion during treatment provided were major concerns expressed by women. 13
Design of quality indicator measurement tools which include and consider the patient’s perspective towards improving their own quality of care can be a promising step towards reducing major outcomes caused by obstetric hemorrhage.4,13 This study aimed to understand and identify the educational gaps among providers and patients towards prevention and management of PPH to reduce maternal morbidity and mortality.
Materials and methods
We conducted a cross-sectional anonymous survey with pregnant or previously pregnant subjects. In addition, providers survey was sent through the Obstetrics and Gynecology department email list serve which included maternal-fetal medicine providers, generalists, certified nurse-midwives and labor and delivery registered nurses in an outpatient practice affiliated with a large academic medical center in Washington, DC. This study was considered exempt by the institutional review board (IRB) at The George Washington University. This survey was based on a prior survey study of PPH practice patterns published in the literature. 16
Using the Babyscripts platform (e BabyScripts TM phone app) we reached out to subjects by email or text with a link to access the survey. We estimated there would be a response of at least 500 patients registered on this platform at our institution based on prior conducted survey studies using Babyscripts. 17 Before beginning the survey, patients and providers were introduced to a brief consent form that included relevant background information as well as the purpose of our study. Surveys were completed using the Research Electronic Data Capture (REDCap) platform and responses were collected from November 2022 to June 2023. Two distinct surveys were formulated in English, with one specifically tailored for providers and the other designed for patients. For patients, the questions focused on (1) risk factors for PPH, (2) clinical presentation of PPH, and (3) perspectives on PPH management. Questions for providers focused mainly on PPH clinical risk assessment, use of TXA for PPH treatment and management of anemic patients. Basic descriptive statistical analysis was conducted using Stata Statistical Software Release 16 (College Station, TX StataCorp. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC; 2019). 18 A copy of the surveys is included in the Supplementary section. Women under the age of 18 and those who without English proficiency were excluded from the study.
Results
Demographics
Demographic data (n = 628).
Data are n (%) or mean ± standard deviation.
Knowledge and attitudes towards PPH
Assessment of risk factors among pregnant population
When asked whether they knew the risk factors for PPH more than half of the participants reported they did not know, less than a third responded maybe, and 16% (n = 102) stated they knew the risk factors. When provided a list of risk factors for PPH, patients were not able to consistently identify high risk characteristics. Only 78% of patients identified anemia as a risk factor for PPH, 68% could identify repeat cesarean delivery, and 57% could identify multiple gestation.
Patient knowledge and behavioral factors associated with PPH management
Patient knowledge regarding obstetric hemorrhage presentation & management.
Data are presented as number (%).
Behavioral factors associated with postpartum hemorrhage management.
Data are presented as number (%).
Open-ended responses
Responses to the question “Are you worried about having a postpartum hemorrhage?” are shown in Figure 1. A majority of the participants were worried in some way about having PPH and approximately 10% (n = 67) of these shared comments surrounding their experience. The primary themes identified included fear of death (n = 10), avoidance of pregnancy (n = 4) and ongoing mood disorders (n = 10) due to previous history of hemorrhage, and proper clinical care among their main concerns. Patients with a history of PPH report fear and trauma related to their experience that influences their decision for future pregnancy. Participants also described concerns regarding the adequacy of care received during a previous hemorrhage event. Some questioned if their experience could have been avoided by receiving different management and having a different approach from their providers. Patient concerns regarding PPH. Caption: Level of concern about having a hemorrhage among pregnant participants. PPH: postpartum hemorrhage.
Fear of death and avoidance of future pregnancy
“I’m concerned about hemorrhaging during delivery and dying” “It’s the number one cause of maternal death. I have a history of retained placenta and manual extraction. There are so many things that could pop up as risk factors for hemorrhage in a future pregnancy. You never know” “I had one, it is a big factor in not wanting to be pregnant again” “I hemorrhaged with all of my births, which caused some serious health concerns and fears for me. I am expecting again and terrified to go into labor because of this. Doctors were able to stop the bleeding, but I never understood why it happened in the first place” “I experienced PPH after delivery with a forceps delivery, resulting in 3b laceration. Two months later, I experienced another hemorrhage after a D&C for retained placenta which resulted in a subsequent hospitalization and needing a blood transfusion. Fear of PPH and possible death is a large factor partner and I’s decision if we want to have more children” “My concern is that hemorrhage will be worse if I get pregnant again and that I won’t be so lucky next time. So, I decided to avoid the risk by not having any more children.”
Mood disorders as consequence of previous episode of hemorrhage
“I had one with my first baby and was very nervous it would happen again the second time, but thankfully it didn’t. If I have another child, I would be anxious again” “I’m still struggling with PTSD from two hemorrhages.”
Level of care provided
“When I was pregnant, I was very concerned about PPH because I read a lot of articles about women especially African American women either dying or having near death experiences related to post-partum hemorrhage. Often, doctors did not listen to women especially African American women or partners when they expressed concern that something was wrong.” “Worried about too much bleeding and my providers not taking my concerns seriously.” “That doctors would not know it was serious enough to address.” “I worry about the preparedness of the hospital team to recognize and address a hemorrhage.”
PPH stratification and management among providers
Of the 22 providers from the same institution, all of them reported they stratify patients by hemorrhage risk on admission to labor and delivery and at least 19 (87%) use a specific stratification system. Upon inquiry about the prophylactic use of tranexamic acid (TXA) before delivery for high-risk patients with hemorrhage risk factors, responses exhibited a remarkable degree of variability. Twelve (54%) providers report not using it prophylactically and 10 (46%) report using it prophylactically (Figure 2). Of the 10 providers that responded YES to giving it prophylactically, 9 of them responded they gave it “at cord clamp and just 1 responded “at or right before skin incision.” Exceedingly, a majority of providers, 64% (n = 14) feel very confident, and 9% (n = 2) feel somewhat confident using TXA at the time of delivery for PPH treatment. The providers’ level of confidence to use TXA at the time of delivery for PPH is presented in Figure 3. Administration of TXA. Caption: Providers decision and timing regarding prophylactic TXA administration. TXA: tranexamic acid. Providers confidence level in using TXA. Caption: Extent of confidence among providers in utilizing TXA during childbirth to treat PPH. TXA: tranexamic acid; PPH: postpartum hemorrhage.
To better understand the variability in PPH management practices, we conducted a more detailed analysis of the provider responses. This analysis revealed differences in the use of TXA, stratification systems, and management approaches for high-risk patients. For example, providers who reported higher confidence in using TXA were more likely to use it prophylactically, suggesting a potential relationship between confidence levels and clinical practice. Furthermore, the variability in stratification systems highlights the lack of standardized guidelines and the need for consensus on best practices for PPH management.
Discussion
Principal findings
Our findings indicate that patients are concerned about developing PPH and recognize bleeding as a contributor to morbidity and mortality. For some patients, a prior experience with PPH leads to avoidance of future pregnancy or mood disorder. Despite this, patients could not consistently identify risk factors for PPH when prompted. While a majority of participants were unaware of the existence of standard medications administered at delivery to prevent hemorrhage, a substantial portion of patients are open to receiving a preventative medication to avoid PPH. More than half of patients report openness to accepting a medication other than oxytocin to prevent PPH. Some patients with a prior hemorrhage indicated concern that the bleeding episode was not recognized or managed appropriately. Patients in our study were interested in more information about hemorrhage and medication that can be used to prevent bleeding.
We also found variations among providers when using a specific hemorrhage risk stratification system and regarding assessment and management of risk factors such as anemia. In addition, discrepancies were also found when deciding how to administer medications such as TXA (i.e., for treatment or prevention of PPH). To address these issues, it is essential to implement strategies that can bridge the educational gaps among patients and providers and translate these findings into practical interventions.
Results
Existing research evaluating attitudes and practices surrounding obstetric hemorrhage have focused on implementing a hemorrhage risk score that can be standardized nationwide and more importantly prove to be effective, in a conjunct effort to reduce preventable maternal morbidity and mortality.4,19–21 Similar to other studies we found major concerns from patients regarding the level of care and the information received from healthcare providers before and during delivery. Interestingly, major concerns were related to psychological outcomes after having a hemorrhage experience, fear of death and lastly an expressed desire to receive more information and reassurance about management.9–12
These findings align with a global calling for adoption of both clinical and non-clinical risk reduction strategies that investigate the involvement of patients in the risk stratification systems and implementation of tools to address their concerns and evaluate their perspectives and preferences toward hemorrhage risks, treatment and medication administration.4,9,10,12,13
Little is known about the providers’ attitudes towards the protocols and management guidelines to which they adhere to. Discrepancies and variability among them are just a reflection of the lack of agreement upon screening systems and medical treatments. Existing literature mainly focus on the negative impact on women after hemorrhage.4,5,10,13 Our study highlights the importance of evaluating patients and providers concerns and further identification of educational gaps towards an effective shared clinical management.
Clinical implications
Addressing obstetric hemorrhage through patients and providers perspective can lead to a newer and more effective approach to prevention and management of PPH. There is a need for each facility to factor in patient and provider perspectives into the education tools and application of their risk stratification system. Labor and deliveries are required to have a hemorrhage risk stratification system for laboring patients. However, there is such variability in how this information is (1) disseminated to the team (2) shared with patients and (3) implemented into actionable risk reducing behaviors (use of medication such as TXA, crossmatching blood type, assessment of blood loss, and initiation of transfusion). This approach will lead to optimal interventions that can have a major positive impact on hemorrhage outcomes and improve patient safety. 4 Our findings show that a large proportion of providers identify high risk patients and administer TXA prior to delivery.
Based on our results we know that innovative treatment approaches such as the use of TXA prophylactically are well received among obstetric patients. A vast majority of studies have shown mixed findings about benefit of TXA for PPH prevention, but timing in large clinical trials is always at umbilical cord clamp which may be too late to show maximum benefit for hemorrhage reduction.22–24 Large clinical trials are needed to evaluate the optimal timing and efficacy at hemorrhage reduction at delivery.
Guiding patients throughout their pregnancy and addressing educational gaps can improve preventable hemorrhage morbidity outcomes, including developing severe anxiety or post-traumatic stress disorder. Interventions based on establishing continued informative communication with patients may be valuable. Communication and education about PPH risk factors can help inform patients of their risk and include patients in the discussion regarding prevention and risk reducing strategies.9,13,14
Regular educational workshops and training sessions should be conducted to ensure that all healthcare providers are up-to-date with the latest PPH management guidelines and risk stratification systems. These sessions should focus on standardizing the use of TXA, as well as enhancing providers’ confidence in managing PPH. Comprehensive patient education programs should be developed, including informational brochures, videos, and interactive sessions about PPH risk factors, prevention strategies, and management options. This will help patients make informed decisions and reduce anxiety related to PPH. Additionally, standardized PPH management guidelines should be established and disseminated across healthcare institutions to reduce variability in clinical practices. To further enhance communication, tools such as checklists and standardized communication protocols should be implemented to ensure that critical information about PPH risk and management is consistently shared among the healthcare team and with patients.
The insights gained from patient responses should be integrated into care plans that are more responsive to their concerns and preferences. This includes addressing psychological outcomes, providing reassurance, and involving patients in decision-making processes. Quality improvement initiatives should be launched, focusing on monitoring and evaluating the implementation of standardized PPH management protocols. Regular audits and feedback mechanisms can help identify areas for improvement and ensure adherence to best practices. Collaborative research efforts should be encouraged to further explore the effectiveness of different PPH prevention and management strategies. Larger studies involving multiple institutions can provide more robust data and help refine guidelines. Finally, promoting patient-centered care models that prioritize patient education, shared decision-making, and continuous communication can enhance patient satisfaction and improve overall outcomes.
Research implications
Additional research with larger sample sizes is needed to expand our knowledge regarding patients and providers’ perspectives and approach. Creation of surveys and questionnaires focused in addressing educational gaps would inform future work in PPH prevention and preparedness. Hence, larger studies are needed to develop a standardized approach to using risk assessment tools, as well as hemorrhage management protocols that could be used widely among all healthcare institutions and in different clinical settings. Standardized approaches to care would minimize the extensive variation that exists among providers when choosing which stratification system might be helpful to use. Discrepancies among providers in management of major risk factors for hemorrhage such as anemia, could also be addressed by future research on this topic and further creation of generalizable protocols and tools. Moreover, patient participation in the risk stratification system should be assessed in larger qualitative studies.
Strengths and limitations
Our study had a large sample size and responses from patients at a large urban academic care center. However, there are several limitations to our study. One limitation of this study was recall bias. Two thirds of the participants were patients that were not currently pregnant but rather have had a previous pregnancy, this might have impacted some of the responses as patients may not be able to accurately recall their previous experiences and are likely to respond differently than currently pregnant patients. Additionally, the reliance on self-reported data introduces the possibility of response bias, as participants may not accurately report their knowledge, attitudes, or practices. Self-reported data can be influenced by social desirability bias, where respondents provide answers they believe are expected or favorable. Future studies could mitigate this bias by incorporating objective measures, such as medical records review or observational data.
The survey was distributed to English-speaking patients in a single healthcare institution. Although this represents to a large extent the patient population attending this healthcare practice, it certainly constitutes a language barrier which may have impacted the diversity of responses and may not be generalizable to all populations. Including non-English speaking patients in future research would provide a more comprehensive understanding of patient perspectives and experiences regarding PPH. Furthermore, expanding the reach of our survey to include multiple institutions will result in a larger sample size of patients and providers and enhance the generalizability of the findings.
Another limitation is the relatively small sample size of providers. Our sample included 22 respondents, comprising certified nurse-midwives, labor and delivery registered nurses, a resident, and a nurse leader, in addition to certified Obstetricians or Maternal-Fetal Medicine specialists. This small sample size may impact the robustness of the conclusions drawn from the provider data, and limit our ability to conduct more detailed subgroup analysis, as it may not fully capture the diversity of clinical practices and attitudes towards PPH management across different provider types and institutions. Expanding providers sample size and evaluating providers with medication administering capacity might reveal significant associations regarding management and stratification of patients with PPH.
Conclusions
Our findings indicate that patients are concerned about hemorrhage, but the vast majority of subjects did not know or were uncertain about the risk factors for PPH. The majority of participants are willing to receive preventive medication and are interested in learning more about preventative medication. Practice patterns in regard to the prevention and management of hemorrhage should be part of a shared decision making between patients and providers. Moreover, our findings validate the significance of engaging patients in their healthcare and also emphasize the need to address knowledge gaps among both patients and healthcare providers.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded through a National Heart, Lung, and Blood Institute grant (K23HL141640).
